Antibiotic prescribing and associated diarrhoea: a prospective cohort study of care home residents

Instruments and Warning Signs for Identifying and Evaluating the Frequency of Adverse Events in Intermediate and Long-Term Care Centres: A Narrative Systematic Review

INTRODUCTION

There is a lack of data about adverse events (AE) in intermediate and long-term care centers (ILCC). We aimed to synthesize the available scientific evidence on instruments used to identify and characterize AEs. We also aimed to describe the most common adverse events in ILCCs.

MATERIAL AND METHODS

A narrative systematic review of the literature was conducted according to Prisma recommendations. The PubMed database was searched for articles published between 2000 and 2021. Two reviewers independently screened and reviewed the studies through blind and independent review. We evaluated bias risk with Cochrane's risk of bias tool. Disagreements were resolved by consensus. Discrepancies that were not resolved by discussion were discussed with a third reviewer. Descriptive data was extracted and qualitative content analysis was performed.

RESULTS

We found 2191 articles. Based on the inclusion and exclusion criteria, 272 papers were screened by title and abstract, and 66 studies were selected for full review. The instruments used to identify AEs were mostly tools to identify specific AEs or risks of AEs (94%), the remaining 6% were multidimensional. The most frequent categories detected medication-related AEs (n=26, 40%); falls (n=7, 11%); psychiatric AEs (6.9%); malnutrition (4.6%), and infections (4.6%). The studies that used multidimensional tools refer to frailty, dependency, or lack of energy as predictors of AEs. However, they do not take into account the importance of detecting AEs. We found 2-11 adverse drug events (ADE) per resident/month. We found a prevalence of falls (12.5%), delirium (9.6-89%), pain (68%), malnutrition (2-83%), and pressure ulcers (3-30%). Urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis were the most common infections in this setting. Transitions between different care settings (from hospitals to ILCC and vice versa) expose AE risk.

CONCLUSION

There are many instruments to detect AEs in ILCC, and most have a specific approach. Adverse events affect a significant proportion of patients in ILCC, the nurse-sensitive outcomes, nosocomial infections, and adverse drug events are among the most common. The systematic review was registered with Prospero, ID: CRD42022348168.

Effects of glycyrrhiza polysaccharides on growth performance, meat quality, serum parameters and growth/meat quality-related gene expression in broilers

With growing restrictions on the use of antibiotics in animal feed, plant extracts are increasingly favored as natural feed additive sources. Glycyrrhiza polysaccharide (GP), known for its multifaceted biological benefits including growth promotion, immune enhancement, and antioxidative properties, has been the focus of recent studies. Yet, the effects and mechanisms of GP on broiler growth and meat quality remain to be fully elucidated. This study aimed to investigate the effects of GP on growth, serum biochemistry, meat quality, and gene expression in broilers. The broilers were divided into five groups, each consisting of five replicates with six birds. These groups were supplemented with 0, 500, 1,000, 1,500, and 2,000 mg/kg of GP in their basal diets, respectively, for a period of 42 days. The results indicated that from day 22 to day 42, and throughout the entire experimental period from day 1 to day 42, the groups receiving 1,000 and 1,500 mg/kg of GP showed a significant reduction in the feed-to-gain ratio (F:G) compared to the control group. On day 42, an increase in serum growth hormone (GH) levels was shown in groups supplemented with 1,000 mg/kg GP or higher, along with a significant linear increase in insulin-like growth factor-1 (IGF-1) concentration. Additionally, significant upregulation of GH and IGF-1 mRNA expression levels was noted in the 1,000 and 1,500 mg/kg GP groups. Furthermore, GP significantly elevated serum concentrations of alkaline phosphatase (AKP) and globulin (GLB) while reducing blood urea nitrogen (BUN) levels. In terms of meat quality, the 1,500 and 2,000 mg/kg GP groups significantly increased fiber density in pectoral muscles and reduced thiobarbituric acid (TBA) content. GP also significantly decreased cooking loss rate in both pectoral and leg muscles and the drip loss rate in leg muscles. It increased levels of linoleic acid and oleic acid, while decreasing concentrations of stearic acid, myristic acid, and docosahexaenoic acid. Finally, the study demonstrated that the 1,500 mg/kg GP group significantly enhanced the expression of myogenin (MyoG) and myogenic differentiation (MyoD) mRNA in leg muscles. Overall, the study determined that the optimal dosage of GP in broiler feed is 1,500 mg/kg.

Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study

BACKGROUND

Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families.

AIM

To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms.

DESIGN & SETTING

A qualitative interview study with primary care clinicians and care home staff in the UK.

METHOD

Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed.

RESULTS

Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas.

CONCLUSION

The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.

Identifying barriers and facilitators to the inclusion of older adults living in UK care homes in research: a scoping review

BACKGROUND

With an ageing population, older adults will have more complex health and social care needs and many of these older adults will be living in care homes. Despite the growth in care home populations, care home residents are often excluded from research that could potentially benefit their care. The purpose of this scoping review is to explore resident-related barriers and facilitators to including older people living in UK care homes in research and to identify potential approaches to modify such barriers.

METHOD

The 6-stage scoping review methodology framework proposed by Arksey and O'Malley guided this review. Five electronic databases (MedLine, PsychINFO, Scopus, Web of Science, CINAHL) and grey literature were searched. Identified articles went through two levels of screening, and those deemed relevant were collated, summarised and reported using a thematic analysis approach.

RESULTS

90 reports were eligible for inclusion and were synthesised into 7 themes and related subthemes: (1) research design; (2) understanding and beliefs about research (resident and care home staff); (3) communication; (4) relationships; (5) eligibility criteria (resident and care home); (6) preference-based decisions; and (7) care home staff and environment. Given the complex interplay of the factors identified, both direct and indirect factors were included.

CONCLUSIONS

A number of recurring barriers and facilitators to the inclusion of care home residents in research are reported. However, isolating resident-related barriers was complex as both direct and indirect factors must be considered as influential. Understanding the barriers and facilitators to inclusion will enable these factors to be addressed and increase the evidence-base for care provided to older people living in care homes.

Lentinan improves intestinal inflammation and gut dysbiosis in antibiotics-induced mice

Gut microbiota dysbiosis is already a global problem after antibiotic overuse. This study was to investigate the therapeutic effect of lentinan and the mechanism of recovery of intestinal inflammation on broad-spectrum antibiotic-driven gut microbial dysbiosis in mice. Gut microbiota was elucidated by the Illumina MiSeq platform. Gas chromatography/mass spectrometry was used to investigate short-chain fatty acid content. Colon histology, expression of tight-junction associated proteins and pro-inflammatory cytokines levels were evaluated. The results showed that the gut microbiota of diversity and richness were reduced and various taxonomic levels of the gut microbiota were perturbed after antibiotics gavage. The abundance of Firmicutes and Bacteroidetes shifted to Proteobacteria and increased the relative abundance of harmful microbiota (Parabacteroides and Klebsiella) post-antibiotics, whereas lentinan administration reversed the dysbiosis and increased beneficial microbiota, including S24-7, Lactobacillus, Oscillospira, Ruminococcus and Allobaculum. The concentrations of propionic acid and butyric acid were significantly increased by treatment with lentinan. And lentinan improved colon tissue morphology and reduced pro-inflammatory cytokines via altering NF-κB signaling pathway in antibiotic-driven gut microbial dysbiosis mice. Taken together, the results proved that lentinan can be used as a prebiotic and the result provided a theoretical basis for improving the clinical treatment of broad-spectrum antibiotics side effects.

Nutrition, Immunosenescence, and Infectious Disease: An Overview of the Scientific Evidence on Micronutrients and on Modulation of the Gut Microbiota

The immune system is key to host defense against pathogenic organisms. Aging is associated with changes in the immune system, with a decline in protective components (immunosenescence), increasing susceptibility to infectious disease, and a chronic elevation in low-grade inflammation (inflammaging), increasing the risk of multiple noncommunicable diseases. Nutrition is a determinant of immune cell function and of the gut microbiota. In turn, the gut microbiota shapes and controls the immune and inflammatory responses. Many older people show changes in the gut microbiota. Age-related changes in immune competence, low-grade inflammation, and gut dysbiosis may be interlinked and may relate, at least in part, to age-related changes in nutrition. A number of micronutrients (vitamins C, D, and E and zinc and selenium) play roles in supporting the function of many immune cell types. Some trials report that providing these micronutrients as individual supplements can reverse immune deficits in older people and/or in those with insufficient intakes. There is inconsistent evidence that this will reduce the risk or severity of infections including respiratory infections. Probiotic, prebiotic, or synbiotic strategies that modulate the gut microbiota, especially by promoting the colonization of lactobacilli and bifidobacteria, have been demonstrated to modulate some immune and inflammatory biomarkers in older people and, in some cases, to reduce the risk and severity of gastrointestinal and respiratory infections, although, again, the evidence is inconsistent. Further research with well-designed and well-powered trials in at-risk older populations is required to be more certain about the role of micronutrients and of strategies that modify the gut microbiota-host relationship in protecting against infection, especially respiratory infection.

Effects of Lacidophilin Tablets, Yogurt, and Bifid Triple Viable Capsules on the Gut Microbiota of Mice with Antibiotic-Associated Diarrhea

Antibiotic-associated diarrhea (AAD) is a common morbidity caused by antibiotic use and is characterized by the dysbiosis of the gut microbiota. Several clinical trials have shown that probiotics can prevent AAD. This study aimed at investigating the effects of Lacidophilin tablets (LB), yogurt (YG), and bifid triple viable capsules (BT) on the gut microbiota of mice with AAD. Mice with diarrhea were randomly allocated to treatment groups or the control group and were treated with either LB, YG, BT, or vehicle control. The body weight, diarrhea scores, cecum index, and cecal length were determined. Fecal samples of all mice were analyzed using 16S rRNA high-throughput sequencing. The results showed that LB, YG, and BT significantly decreased the diarrhea scores and inhibited increases in the cecum index and cecal length induced by AAD. In addition, they significantly changed the composition and richness of the gut microbiota. Specifically, they increased the abundance of the phylum Firmicutes and decreased the abundance of the phyla Bacteroidetes and the family Bacteroidaceae. Treatment with LB and YG also decreased the abundance of the phylum Proteobacteria and only LB could mediate the reduced levels of Lactobacillaceae in AAD mice. At the genus level, YG and BT treatment decreased the abundance of Bacteroides or Parasutterella. To our surprise, only LB treatment dramatically increased the abundance of Lactobacillus and decreased that of potential pathogens, such as Bacteroides, Parabacteroides, and Parasutterella, to almost normal values. Our findings indicate that LB, YG, and BT ameliorated diarrhea by regulating the composition and structure of the gut microbiota and that LB plays an important role in regulating the gut microbiota.

Making progress: but a way to go-the age and ageing care-home collection

Care homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to the coronavirus disease 2019 (COVID-19) response. We searched Age and Ageing for care-home articles published since 2015. From these we collated 42 into the Age and Ageing care-home collection. This collection draws together important papers that show how Age and Ageing is helping to shape and grow care-home research. The  collection outlines the technical issues that researchers face by grouping together important feasibility trials conducted in the sector. It looks at the challenges of measuring quality of life and working with routine data in care homes. It brings together observational studies considering loneliness, functional dependency, stroke outcomes, prescribing and acute deterioration. Health services research in care homes is represented by two studies that demonstrate realist evaluation as a way to make sense of service innovations. Papers are included that consider: non-pharmacological strategies for residents with dementia, end-of-life care, sexuality and intimacy and the care-home workforce. Given the importance of the COVID-19 pandemic in care homes, all of the care home COVID-19 papers published in Age and Ageing to date are included. Finally, a group of papers that present innovative approaches to research in care homes, each of which give voice to residents and/or staff, are collated and presented as a way of moving towards a more resident and care home centred research agenda.

Effects of Bacteroides-Based Microecologics against Antibiotic-Associated Diarrhea in Mice

Antibiotic-associated diarrhea (AAD) is a self-limiting disease mediated by antibiotic therapy. In clinical practice, several types of probiotics are used in treating AAD, but minimal research has been done on Bacteroides-based microecologics. Our aim was to evaluate the therapeutic effects of Bacteroidetes uniformis FGDLZ48B1, B. intestinalis FJSWX61K18, Bifidobacterium adolescentis FHNFQ48M5, and B. bifidum FGZ30MM3 and their mixture on AAD in mice. The lincomycin hydrochloride-induced AAD models were gavaged with a single strain or a probiotic mixture for a short period to assess the changes in colonic histopathology and cytokine concentrations, intestinal epithelial permeability and integrity, short-chain fatty acids (SCFAs), and the diversity of intestinal microbiota. Our data indicated that both the sole use of Bacteroides and the combination of Bacteroides and Bifidobacterium beneficially weakened systemic inflammation, increased the recovery rate of tissue structures, increased the concentrations of SCFAs, and restored the gut microbiota. Moreover, the probiotic mixture was more effective than the single strain. Specifically, B. uniformis FGDLZ48B1 combined with the B. adolescentis FHNFQ48M5 group was more effective in alleviating the pathological features of the colon, downregulating the concentrations of interleukin (IL)-6, and upregulating the expression of occludin. In summary, our research suggests that administration of a mixture of B. uniformis FGDLZ48B1 and B. adolescentis FHNFQ48M5 is an effective approach for treating AAD.

Temporal and regional trends of antibiotic use in long-term aged care facilities across 39 countries, 1985-2019: Systematic review and meta-analysis

BACKGROUND

Antibiotic misuse is a key contributor to antimicrobial resistance and a concern in long-term aged care facilities (LTCFs). Our objectives were to: i) summarise key indicators of systemic antibiotic use and appropriateness of use, and ii) examine temporal and regional variations in antibiotic use, in LTCFs (PROSPERO registration CRD42018107125).

METHODS & FINDINGS

Medline and EMBASE were searched for studies published between 1990-2021 reporting antibiotic use rates in LTCFs. Random effects meta-analysis provided pooled estimates of antibiotic use rates (percentage of residents on an antibiotic on a single day [point prevalence] and over 12 months [period prevalence]; percentage of appropriate prescriptions). Meta-regression examined associations between antibiotic use, year of measurement and region. A total of 90 articles representing 78 studies from 39 countries with data between 1985-2019 were included. Pooled estimates of point prevalence and 12-month period prevalence were 5.2% (95% CI: 3.3-7.9; n = 523,171) and 62.0% (95% CI: 54.0-69.3; n = 946,127), respectively. Point prevalence varied significantly between regions (Q = 224.1, df = 7, p<0.001), and ranged from 2.4% (95% CI: 1.9-2.7) in Eastern Europe to 9.0% in the British Isles (95% CI: 7.6-10.5) and Northern Europe (95% CI: 7.7-10.5). Twelve-month period prevalence varied significantly between regions (Q = 15.1, df = 3, p = 0.002) and ranged from 53.9% (95% CI: 48.3-59.4) in the British Isles to 68.3% (95% CI: 63.6-72.7) in Australia. Meta-regression found no association between year of measurement and antibiotic use prevalence. The pooled estimate of the percentage of appropriate antibiotic prescriptions was 28.5% (95% CI: 10.3-58.0; n = 17,245) as assessed by the McGeer criteria. Year of measurement was associated with decreasing appropriateness of antibiotic use over time (OR:0.78, 95% CI: 0.67-0.91). The most frequently used antibiotic classes were penicillins (n = 44 studies), cephalosporins (n = 36), sulphonamides/trimethoprim (n = 31), and quinolones (n = 28).

CONCLUSIONS

Coordinated efforts focusing on LTCFs are required to address antibiotic misuse in LTCFs. Our analysis provides overall baseline and regional estimates for future monitoring of antibiotic use in LTCFs.

Regulatory effect of non-starch polysaccharides from purple sweet potato on intestinal microbiota of mice with antibiotic-associated diarrhea

Antibiotic treatment causes antibiotic-associated diarrhea (AAD), which is usually accompanied by disorders of the intestinal flora, aggravating the patient's condition. Recently, more attention has been devoted to the ability of plant polysaccharides to improve the body's flora and enhance immunity. However, reports on whether purple sweet potato polysaccharides (PSPPs) can improve AAD are scarce. This study aimed to extract a non-starch polysaccharide from purple sweet potato and analyze its structure and ability to regulate the intestinal flora of mice with AAD. The diarrhea model was established via intragastric administration of lincomycin and different concentrations of PSPPs (0.1 g kg-1, 0.2 g kg-1, and 0.4 g kg-1) to Balb/C mice. The results showed that PSPP was a pyran polysaccharide with 1 → 2, 1 → 2, 6, 1 → 4, 1 → 4, 6 glycosidic bonds in an α-configuration. In vivo experiments showed that PSPP could relieve diarrhea and improve the structural damage in the ileum caused by lincomycin hydrochloride. In addition, treatment with PSPPs decreased the levels of IL-1β, IL-6 and TNF-α but increased the level of IL-10 in the intestines of mice (p < 0.01). The results of 16S rRNA sequencing showed that PSPPs changed the composition and diversity of the intestinal flora of mice with AAD. In addition, PSPP treatment increased the content of short-chain fatty acids (p < 0.01). These results revealed that PSPPs regulated the intestinal flora, balanced fatty acid metabolism, and relieved the symptoms of diarrhea to a certain extent in mice.

Effect of Probiotic Use on Antibiotic Administration Among Care Home Residents: A Randomized Clinical Trial

IMPORTANCE

Probiotics are frequently used by residents in care homes (residential homes or nursing homes that provide residents with 24-hour support for personal care or nursing care), although the evidence on whether probiotics prevent infections and reduce antibiotic use in these settings is limited.

OBJECTIVE

To determine whether a daily oral probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 compared with placebo reduces antibiotic administration in care home residents.

DESIGN, SETTING, AND PARTICIPANTS

Placebo-controlled randomized clinical trial of 310 care home residents, aged 65 years and older, recruited from 23 care homes in the United Kingdom between December 2016 and May 2018, with last follow-up on October 31, 2018.

INTERVENTIONS

Study participants were randomized to receive a daily capsule containing a probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 (total cell count per capsule, 1.3 × 1010 to 1.6 × 1010) (n = 155), or daily matched placebo (n = 155), for up to 1 year.

MAIN OUTCOMES AND MEASURES

The primary outcome was cumulative antibiotic administration days for all-cause infections measured from randomization for up to 1 year.

RESULTS

Among 310 randomized care home residents (mean age, 85.3 years; 66.8% women), 195 (62.9%) remained alive and completed the trial. Participant diary data (daily data including study product use, antibiotic administration, and signs of infection) were available for 98.7% randomized to the probiotic group and 97.4% randomized to placebo. Care home residents randomized to the probiotic group had a mean of 12.9 cumulative systemic antibiotic administration days (95% CI, 0 to 18.05), and residents randomized to placebo had a mean of 12.0 days (95% CI, 0 to 16.95) (absolute difference, 0.9 days [95% CI, -3.25 to 5.05]; adjusted incidence rate ratio, 1.13 [95% CI, 0.79 to 1.63]; P = .50). A total of 120 care home residents experienced 283 adverse events (150 adverse events in the probiotic group and 133 in the placebo group). Hospitalizations accounted for 94 of the events in probiotic group and 78 events in the placebo group, and deaths accounted for 33 of the events in the probiotic group and 32 of the events in the placebo group.

CONCLUSIONS AND RELEVANCE

Among care home residents in the United Kingdom, a daily dose of a probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 did not significantly reduce antibiotic administration for all-cause infections. These findings do not support the use of probiotics in this setting.

TRIAL REGISTRATION

ISRCTN Identifier:16392920.

Antibiotic prescribing in UK care homes 2016-2017: retrospective cohort study of linked data

BACKGROUND

Older people living in care homes are particularly susceptible to infections and antibiotics are therefore used frequently for this population. However, there is limited information on antibiotic prescribing in this setting. This study aimed to investigate the frequency, patterns and risk factors for antibiotic prescribing in a large chain of UK care homes.

METHODS

Retrospective cohort study of administrative data from a large chain of UK care homes (resident and care home-level) linked to individual-level pharmacy data. Residents aged 65 years or older between 1 January 2016 and 31 December 2017 were included. Antibiotics were classified by type and as new or repeated prescriptions. Rates of antibiotic prescribing were calculated and modelled using multilevel negative binomial regression.

RESULTS

13,487 residents of 135 homes were included. The median age was 85; 63% residents were female. 28,689 antibiotic prescriptions were dispensed, the majority were penicillins (11,327, 39%), sulfonamides and trimethoprim (5818, 20%), or other antibacterials (4665, 16%). 8433 (30%) were repeat prescriptions. The crude rate of antibiotic prescriptions was 2.68 per resident year (95% confidence interval (CI) 2.64-2.71). Increased antibiotic prescribing was associated with residents requiring more medical assistance (adjusted incidence rate ratio for nursing opposed to residential care 1.21, 95% CI 1.13-1.30). Prescribing rates varied widely by care home but there were no significant associations with the care home-level characteristics available in routine data.

CONCLUSIONS

Rates of antibiotic prescribing in care homes are high and there is substantial variation between homes. Further research is needed to understand the drivers of this variation to enable development of effective stewardship approaches that target the influences of prescribing.

Characteristics of Clostridium difficile isolates and the burden of hospital-acquired Clostridium difficile infection in a tertiary teaching hospital in Chongqing, Southwest China

BACKGROUND

Clostridium difficile infection (CDI), especially hospital-acquired Clostridium difficile infection (HA-CDI), continues to be a public health problem and has aroused great concern worldwide for years. This study aimed to elucidate the clinical and epidemiological features of HA-CDI and the characteristics of C.difficile isolates in Chongqing, Southwest China.

METHODS

A case-control study was performed to identify the clinical incidence and risk factors of HA-CDI. C. difficile isolates were characterised by polymerase chain reaction (PCR) ribotyping, multilocus sequence typing (MLST), toxin gene detection and antimicrobial susceptibility testing.

RESULTS

Of the 175 suspicious patients, a total of 122 patients with antibiotic-associated diarrhea (AAD) were included in the study; among them, 38 had HA-CDI. The incidence of AAD and HA-CDI was 0.58 and 0.18 per 1000 patient admissions, respectively. Chronic renal disease and cephalosporin use were independent risk factors for HA-CDI. Fifty-five strains were assigned into 16 sequence types (STs) and 15 ribotypes (RTs). ST2/RT449 (8, 14.5%) was the predominant genotype. Of the 38 toxigenic isolates, A + B + CDT- isolates accounted for most (34, 89.5%) and 1 A + B + CDT+ isolate emerged. No isolate was resistant to vancomycin, metronidazole or tigecycline, with A-B-CDT- being more resistant than A + B + CDT-.

CONCLUSIONS

Different genotypes of C. difficile strains were witnessed in Chongqing, which hinted at the necessary surveillance of HA-CDI. Adequate awareness of patients at high risk of HA-CDI acquisition is advocated and cautious adoption of cephalosporins should be highlighted.

Effects of Hetiao Jianpi Decoction on Intestinal Injury and Repair in Rats with Antibiotic-Associated Diarrhea

BACKGROUND Through observing the changes of indexes of the intestinal mucosal barrier and intestinal flora in rats, we explored the mechanism by which Hetiao Jianpi Decoction (HTJPD) treats antibiotic-associated diarrhea (AAD) by repairing intestinal mucosal injury and regulating intestinal flora. MATERIAL AND METHODS Samples of colon tissues were collected for HE staining. Enzyme-linked immunosorbent assay (ELISA) was used to assess levels of diamine oxidase (DAO) and D-lactic acid in rat plasma and the expression of secretory immunoglobulin A (SIgA) in colon tissue. We assessed the abundance of intestinal contents by high-throughput sequencing of the 16S rRNA gene. RESULTS Compared with the Model group, the muscle layer and intestinal mucosal edema were improved, and the continuity was restored; the levels of DAO and D-lactic acid in plasma decreased, and the SIgA level were increased in the HTJPD group. The structure of the intestinal flora changed, as indicated by increased levels of certain beneficial bacteria (Verrucomicrobia, Actinobacteria, CF231, and Akkermansia), decreased levels of pathogenic bacteria (Spirochaetes and Treponema), and increased species diversity. CONCLUSIONS By improving the permeability and immune function of the intestinal mucosa, Hetiao Jianpi decoction prevented the occurrence of AAD by repairing the intestinal mucosal damage and regulating the structure and diversity of intestinal flora.

Antimicrobial stewardship in care homes: outcomes of importance to stakeholders

BACKGROUND

Heterogeneity of outcomes measured in trials to improve antimicrobial stewardship (AMS) in care homes has compromised quality of evidence. A core outcome set (COS) is needed to facilitate interpretation and synthesis of evidence in this area.

AIM

To determine outcomes deemed important by relevant stakeholders for interventions aimed at improving AMS in care homes, and to produce a refined list of outcomes that could be considered for use in future research.

METHODS

Semi-structured face-to-face or telephone interviews were conducted with key stakeholders. Outcomes reported in previous randomized controlled trials (RCTs) of AMS in care homes were included in a topic guide for interviews. Content analysis was undertaken to identify potential outcomes suggested by participants, followed by further review.

FINDINGS

Twenty-seven outcomes reported in RCTs were refined into a list of 12 overarching outcomes. Interviews with participants (six researchers, 31 healthcare professionals, and four family members of care home residents) identified 40 additional outcomes that were important to them. From these 52 outcomes, the total number of antimicrobials, the appropriateness of antimicrobial prescribing and adherence to guidelines were highlighted by most participants. After reviewing all 52 outcomes, a refined list of 14 outcomes potentially feasible for use in AMS trials in care homes was generated.

CONCLUSION

s: A number of potential outcomes for AMS in care homes, some of which had not been reported in previous studies, were identified. The refined list of 14 outcomes will be used in a future study to agree a COS for care home AMS trials.

Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study

Background:Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses' influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents. Design and methods:An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016. Results:Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents' infections. Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency.

Effects of Panax ginseng polysaccharides on the gut microbiota in mice with antibiotic-associated diarrhea

Panax ginseng is a traditional medicinal plant used in most Asian countries to cure many diseases. The benefits of ginseng are due to its primary active component, polysaccharides. Gut microbiota dysbiosis is a worldwide problem associating with antibiotic use. The objective of this study was to investigate the effects of ginseng polysaccharides (WGP) on the diversity of the gut microbiota in mice with antibiotic-associated diarrhea. Compared to diarrhea mice, WGP significantly changed the composition and diversity of the gut microbiota. Specifically, WGP increased the relative abundance of the phylum Firmicutes and decreased the relative abundance of the phyla Bacteroidetes, Proteobacteria and Actinobacteria. At the genus level, WGP increased the relative abundance of Lactobacillus, Lactococcus, and Streptococcus, but decreased the relative abundance of Bacteroides. The key phylotype of beneficial bacteria in the gut microbiota that responded to WGP was Lactobacillus. In addition, WGP also reversed carbohydrate, amino acid and energy metabolism to normal levels, thereby promoting the recovery of the mucosal structure. Taken collectively, our results indicate that WGP altered the composition and diversity of the gut microbiota in mice with antibiotic-associated diarrhea, restored the gut microbiota, balanced metabolic processes, and promoted the recovery of the mucosa.

Impact of Amoxicillin-Clavulanate followed by Autologous Fecal Microbiota Transplantation on Fecal Microbiome Structure and Metabolic Potential

The spread of multidrug resistance among pathogenic organisms threatens the efficacy of antimicrobial treatment options. The human gut serves as a reservoir for many drug-resistant organisms and their resistance genes, and perturbation of the gut microbiome by antimicrobial exposure can open metabolic niches to resistant pathogens. Once established in the gut, antimicrobial-resistant bacteria can persist even after antimicrobial exposure ceases. Strategies to prevent multidrug-resistant organism (MDRO) infections are scarce, but autologous fecal microbiota transplantation (autoFMT) may limit gastrointestinal MDRO expansion. AutoFMT involves banking one’s feces during a healthy state for later use in restoring gut microbiota following perturbation. This pilot study evaluated the effect of amoxicillin-clavulanic acid (Amox-Clav) exposure and autoFMT on gastrointestinal microbiome taxonomic composition, resistance gene content, and metabolic capacity. Importantly, we found that metabolic capacity was perturbed even in cases where gross phylogeny remained unchanged and that autoFMT was safe and well tolerated.

Strategies to prevent multidrug-resistant organism (MDRO) infections are scarce, but autologous fecal microbiota transplantation (autoFMT) may limit gastrointestinal MDRO expansion. AutoFMT involves banking one’s feces during a healthy state for later use in restoring gut microbiota following perturbation. This pilot study evaluated the effect of autoFMT on gastrointestinal microbiome taxonomic composition, resistance gene content, and metabolic capacity after exposure to amoxicillin-clavulanic acid (Amox-Clav). Ten healthy participants were enrolled. All received 5 days of Amox-Clav. Half were randomized to autoFMT, derived from stool collected pre-antimicrobial exposure, by enema, and half to saline enema. Participants submitted stool samples pre- and post-Amox-Clav and enema and during a 90-day follow-up period. Shotgun metagenomic sequencing revealed taxonomic composition, resistance gene content, and metabolic capacity. Amox-Clav significantly altered gut taxonomic composition in all participants (n = 10, P < 0.01); however, only three participants exhibited major changes at the phylum level following exposure. In the cohort as a whole, beta-lactamase genes were enriched following Amox-Clav (P < 0.05), and predicted metabolic capacity was significantly altered (P < 0.01). Species composition, metabolic capacity, and beta-lactamase abundance returned to pre-antimicrobial exposure state 7 days after either autoFMT or saline enema (P > 0.05, compared to enrollment). Alterations to microbial metabolic capacity occurred following antimicrobial exposure even in participants without substantial taxonomic disruption, potentially creating open niches for pathogen colonization. Our findings suggest that metabolic potential is an important consideration for complete assessment of antimicrobial impact on the microbiome. AutoFMT was well tolerated and may have contributed to phylogenetic recovery. (This study has been registered at ClinicalTrials.gov under identifier NCT02046525.)

IMPORTANCE The spread of multidrug resistance among pathogenic organisms threatens the efficacy of antimicrobial treatment options. The human gut serves as a reservoir for many drug-resistant organisms and their resistance genes, and perturbation of the gut microbiome by antimicrobial exposure can open metabolic niches to resistant pathogens. Once established in the gut, antimicrobial-resistant bacteria can persist even after antimicrobial exposure ceases. Strategies to prevent multidrug-resistant organism (MDRO) infections are scarce, but autologous fecal microbiota transplantation (autoFMT) may limit gastrointestinal MDRO expansion. AutoFMT involves banking one’s feces during a healthy state for later use in restoring gut microbiota following perturbation. This pilot study evaluated the effect of amoxicillin-clavulanic acid (Amox-Clav) exposure and autoFMT on gastrointestinal microbiome taxonomic composition, resistance gene content, and metabolic capacity. Importantly, we found that metabolic capacity was perturbed even in cases where gross phylogeny remained unchanged and that autoFMT was safe and well tolerated.

Vulnerability of long-term care facility residents to Clostridium difficile infection due to microbiome disruptions

Aging presents a significant risk factor for Clostridium difficile infection (CDI). A disproportionate number of CDIs affect individuals in long-term care facilities compared with the general population, likely due to the vulnerable nature of the residents and shared environment. Review of the literature cites a number of underlying medical conditions such as the use of antibiotics, proton pump inhibitors, chemotherapy, renal disease and feeding tubes as risk factors. These conditions alter the intestinal environment through direct bacterial killing, changes to pH that influence bacterial stabilities or growth, or influence nutrient availability that direct population profiles. In this review, we examine some of the contributing risk factors for elderly associated CDI and the toll they take on the microbiome.

Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities

BACKGROUND

Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting.

OBJECTIVES

This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting.

SOURCE

PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively.

CONTENT

Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions.

IMPLICATIONS

There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Oral administration of Bifidobacterium bifidum G9-1 alleviates rotavirus gastroenteritis through regulation of intestinal homeostasis by inducing mucosal protective factors

Human rotavirus (RV) infection is a leading cause of dehydrating diarrhea in infants and young children worldwide. Since therapeutic approaches to RV gastroenteritis are limited to alleviation of dehydration with oral rehydration solutions, more direct approaches to palliate symptoms of RV gastroenteritis are required. Treatments with probiotics have been increasingly recognized as alternative safe and low cost treatments for moderate infectious diarrhea. In this study, Bifidobacterium bifidum G9-1 (BBG9-1), which has been used as an intestinal drug for several decades, was shown to have a remarkable protective effect against RV gastroenteritis in a suckling mice model. As well as prophylactic oral administration of BBG9-1 from 2 days before RV infection, therapeutic oral administration of BBG9-1 from 1 day after RV infection significantly alleviated RV-induced diarrhea. Therapeutic administration of BBG9-1 reduced various types of damage in the small intestine, such as epithelial vacuolization and villous shortening, and significantly diminished the infectious RV titer in mixtures of cecal contents and feces. It was also shown that therapeutic administration of BBG9-1 significantly increased the number of acidic mucin-positive goblet cells and the gene expression of mucosal protective factors including MUC2, MUC3, MUC4, TGFβ1 and TFF3 in the small intestine. This led to alleviation of low gut permeability shown as decreased gene expression levels of occludin, claudin-1 and villin-1 after RV infection. Furthermore, in the small intestine, therapeutic administration of BBG9-1 significantly palliated the decreased gene expression of SGLT-1, which plays an important role in water absorption. In the large intestine, administered BBG9-1 was shown to replicate to assimilate undigested nutrients, resulting in normalization of the abnormally high osmotic pressure. These results suggested that water malabsorption caused by RV infection was alleviated in mice administered BBG9-1. Thus, the present study showed that oral administration of BBG9-1 palliated diarrhea partly through protection against RV-induced lesions by inducing mucosal protective factors. Oral administration of BBG9-1 is thought to be an efficient method for management of an RV epidemic for both prophylactic and therapeutic purposes.

Structural modulation of gut microbiota during alleviation of antibiotic-associated diarrhea with herbal formula

The gut microbiome is hypothesized to play a critical role in gastrointestinal diseases, including antibiotic-associated diarrhea (AAD). To determine whether the traditional Chinese herbal formula of Shen Ling Bai Zhu San (SLBZS) modulates the composition of the gut microbiome during AAD treatment, an AAD diarrhea model was prepared in rats by gastric gavage with lincomycin for 7 successive days, followed by administration of SLBZS for one week. At all time points after the SLBZS treatment, the diarrhea rates were significantly or at least numerically lower than that of the untreated model group. Overall structural modulation of the gut microbiome occurred after SLBZS treatment, with reverting effects on the AAD-induced structural variations. At the genus level, the relative abundance of Sutterella was negatively correlated with SLBZS treatment and positively correlated with a lack of treatment, suggesting that Sutterella might be a pivotal phylotype associated with the improvement of AAD. The key phylotypes of the gut microbiome that responded to SLBZS indicated enrichment of beneficial bacteria, and particularly Bacteroides spp. These data therefore demonstrated that structural changes of the gut microbiome are induced by the Chinese herbal formula SLBZS. In conclusion, changes in the gut microbiome are associated with the diarrhea-controlling effect of SLBZS.

Nutritional advice for community patients: insights from a panel discussion

This article describes the conclusions of an expert panel that discussed four case studies; these were examples of patients typically encountered by nurses working in the community. The panel considered the nutritional and lifestyle advice that could be given by nurses relating to conditions such as irritable bowel syndrome (IBS), depression, chronic fatigue syndrome, vulnerability to common infections, elderly care, recurrent urinary tract infection, antibiotic use, and risk of type 2 diabetes. A general conclusion was the importance of motivational interviewing techniques in achieving full understanding of patients' concerns and to determine the best health strategy. As well as specific guidance appropriate for each disorder, a range of information sources for both health professionals and patients are listed in the paper. The panel noted that, although general nutritional advice can be given by nurses working at GP surgeries and in the community, patients should always be referred to registered dietitians or nutritionists if significant dietary changes are considered.